Long-term outcome of lung transplantation in previous intravenous drug users with talc lung granulomatosis.

Talc lung granulomatosis results from the intravenous use of medication intended for oral use. Talc (magnesium silicate) acts as filler in some oral medications; when injected intravenously, it deposits in the lungs leading to airflow obstruction and impaired gas exchange. Allocation of donor lungs to previous intravenous drug users is controversial. After a careful selection process, 19 patients with talc lung granulomatosis have received lung allografts in our program. Long-term survival for these patients is excellent and our results suggest the previous use of intravenous drugs should not necessarily preclude lung transplantation.

Cost effectiveness of transbronchial needle aspiration.

OBJECTIVE: To evaluate the yield and cost effectiveness of transbronchial needle aspiration (TBNA) in the assessment of mediastinal and/or hilar lymphadenopathy. DESIGN: Retrospective study. SETTING: A university hospital. POPULATION STUDIED: Ninety-six patients referred for bronchoscopy with computed tomographic evidence of significant mediastinal or hilar adenopathy. RESULTS: Ninety-nine patient records were reviewed. Three patients had two separate bronchoscopy procedures. TBNA was positive in 42 patients (44%) and negative in 54 patients. Of the 42 patients with a positive aspirate, 40 had malignant cytology and two had cells consistent with benign disease. The positive TBNA result altered management in 22 of 40 patients with malignant disease and one of two patients with benign disease, thereby avoiding further diagnostic procedures. The cost of these subsequent procedures was estimated at $27,335. No complications related to TBNA were documented. CONCLUSIONS: TBNA is a high-yield, safe and cost effective procedure for the diagnosis and staging of bronchogenic cancer.

Bronchial mucus properties in lung cancer: relationship with site of lesion.

OBJECTIVE: To compare the biophysical properties of mucus from the left and right mainstem bronchi in patients undergoing diagnostic bronchoscopy because of a unilateral radiological abnormality. It was hypothesized that abnormalities in the properties of mucus would be greater on the side with the lesion and that this would be most obvious in patients with unilateral lung cancer. PATIENTS AND METHODS: Bilateral paired samples of bronchial mucus were taken from 38 nonatopic patients (aged 59.8+/-12.6 years) including 16 nonsmokers, 14 current smokers and eight exsmokers (more than one year). Twenty of the 38 patients had a radiologically defined unilateral abnormality. Eight of these 20, including one nonsmoker, had lung cancer. The viscoelastic properties of the collected mucus were determined by magnetic microrheometry, and the analysis was carried out without knowledge of the histological diagnosis or source. RESULTS: The rheological properties of mucus strongly suggested which was the abnormal side. Within the group of 20 patients with a unilateral radiological abnormality, mucus from the side of the lesion had a lower value of the loss tangent, tan d100 (P=0.004), indicating greater mucus recoil. This is consistent with poor mucus cough clearability on the lesion side. All eight cancer patients fit this mucus rheological pattern with a lower value of tan d100 on the affected side (P=0.007). Four of the five other patients with a similar mucus abnormality were categorized as high cancer risk by other criteria, while six of seven patients with mucus that did not have this abnormality were considered to be lower risk. Based on the mucus analysis done at the time of the bronchoscopy, two of the 'noncancer' patients initially designated as high risk had cancer detected after several months of follow- up. Only two of the 18 patients without a defined unilateral lesion fit the mucus 'cancer pattern'. CONCLUSIONS: These findings are consistent with the hypothesis that either abnormalities in mucus properties may represent a risk factor for the development of lung cancer or that bronchial mucus abnormalities may be associated with products secreted by the tumours that, in turn, may suppress mucus clearance.

Sarcoma of the pulmonary artery trunk: report of a case complicated with hemopericardium and cardiac tamponade.

A 64-year-old woman presented initially with a metastatic spindle-cell sarcoma of the lung of unknown primary. She suddenly died nine months later from hemopericardium with cardiac tamponade caused by partial hemorrhagic necrosis of pulmonary artery trunk sarcoma.

Fibreoptic bronchoscopy in the diagnosis of pulmonary disease in the immunocompromised host in northern Alberta.

OBJECTIVES: To determine the diagnostic utility of bronchoscopy in a population of immunocompromised hosts in northern Alberta. PATIENTS AND METHODS: Results from bronchoscopy in 86 immunocompromised patients who underwent a total of 101 procedures were retrospectively reviewed. RESULTS: The overall diagnostic yield was 57% with the highest yield in patients on immunosuppressive drug therapy (80%) and the lowest yield in the group of bone marrow transplant patients (27%). CONCLUSIONS: Bronchoscopy is a valuable tool for the evaluation of pulmonary disease in the immunocompromised host. Overall diagnostic yield of 57% is comparable with that reported in the literature.

Evaluation of effects of PAF on alveolar fluid clearance with use of NMR imaging.

Autologous serum with or without platelet-activating factor (PAF) was instilled into one lung lobe of an anesthetized cat, and changes in the regional lung water content were monitored for 4 h with proton nuclear magnetic resonance (NMR) images and relaxation time measurements. With serum as an instillate, water was cleared with a half time of approximately 670 min; after 4 h, 86 +/- 6% of that instilled remained. With PAF added to the instillate, clearance was biphasic with an initial clearance half time of approximately 30 min followed by clearance similar to that observed after serum instillation; after 4 h, 35 +/- 4% of that instilled remained. In contrast, 4 h after instillation of serum or serum plus PAF, 91 +/- 3% and 82 +/- 5%, respectively, of the instilled 125I-labeled albumin remained in the lung (P = 0.06). From transverse magnetization relaxation curves we were able to resolve two relaxation components, which we have attributed to the instilled fluid in the air spaces (relaxation time = 177 +/- 7 ms) and the tissue-bound fluid (relaxation time = 25 +/- 1 ms).

Effects of neutrophil depletion and repletion on PAF-induced hyperresponsiveness of canine trachea.

Platelet-activating factor (PAF) has been implicated as a mediator of airway hyperresponsiveness. PAF, infused intra-arterially into the canine cervical trachea, causes adherence of neutrophils to vascular endothelium, increases vascular permeability, and increases the responsiveness of tracheal muscle to parasympathetic stimulation. We hypothesized that the increase in airway responsiveness induced by PAF in this model depends on the presence of neutrophils. To test this hypothesis, we perfused a cervical tracheal segment with autologous blood depleted of leukocytes or with similar leukocyte-depleted blood that had been repleted with its neutrophils. Fifteen minutes after the onset of perfusion with either leukocyte-depleted or neutrophil-repleted blood, PAF infusion was begun into the tracheal arterial vasculature. The contractile response of the tracheal muscle to parasympathetic stimulation was measured before and 15 and 30 min after the onset of PAF infusion. PAF did not significantly change the response of tracheal muscle during perfusion with neutrophil-depleted blood but increased the response of tracheal muscle during perfusion with neutrophil-repleted blood. We conclude that the increase in canine tracheal muscle response induced by intra-arterial PAF depends on neutrophils.

Platelet-activating factor causes neutrophil accumulation and neutrophil-mediated increased vascular permeability in canine trachea.

Platelet-activating factor (PAF) has potent effects on the respiratory airways that may be mediated through its ability to act as an inflammatory stimulant. To study its inflammatory properties in the airways, we infused PAF into the vasculature of the canine trachea and examined (1) the kinetics of neutrophil transit through the tracheal microcirculation, (2) accompanying changes in vascular permeability, and (3) the dependence of vascular permeability changes on neutrophil accumulation. Neutrophil kinetics were assessed by measuring the transit times of fluorescein isothiocyanate-labeled canine neutrophils by in vivo microscopy. Changes in vascular permeability were measured by the extravascular leakage of radiolabeled albumin and comparison of wet-to-dry weight ratios. The importance of neutrophils in increasing vascular permeability was assessed by perfusing the trachea with either autologous blood depleted of its leukocytes, or leukocyte-depleted blood replenished with neutrophils. Our data indicate that PAF causes rapid and prolonged neutrophil accumulation in the canine trachea and an increase in vascular permeability that is partially mediated by neutrophils.

Neutrophil kinetics in the pulmonary microcirculation during acute inflammation.

The site of neutrophil interaction with the vasculature during acute lung inflammation is controversial, but has been suggested to occur in the alveolar capillaries, in contrast with its location in postcapillary venules in nonpulmonary tissues. We studied the kinetics of neutrophil accumulation and the site of neutrophil-vascular interaction in the lung by examining directly the behavior of fluorescein isothiocyanate-labeled canine neutrophils utilizing in vivo fluorescence videomicroscopy through a window inserted into the chest wall of anesthetized dogs. The administration of fragments of the fifth component of complement (C5f) into either the airway or pulmonary artery resulted in neutrophil sequestration almost exclusively in pulmonary capillaries. Kinetically, there was a shift in the distribution of neutrophil transit times resulting in a marked prolongation of median transit time. This response occurred within seconds after intravascular C5f and within 5 minutes after airway C5f and was maintained for at least 30 minutes. Ultrastructural studies after airway C5f showed neutrophils in various stages of migration through the alveolar-capillary membrane and more than 90% of these neutrophils were seen to migrate from capillary rather than from venular sites. These data indicate that pulmonary inflammation differs from inflammation in other vascular beds primarily in the site of neutrophil localization and migration. This fundamental difference in the inflammatory response may serve to localize the inflammatory response to the alveolus, and (since cells were retained singly), indicates the inability of leukoaggregation adequately to explain the findings. Leukocyte accumulation in the lung may thus occur through alterations in the balance between delivery of neutrophils to the lung and the transit time of these cells across the capillary bed.

Sequential changes in canine pulmonary epithelial and endothelial cell functions after nitrogen dioxide.

Through its ability to cause lipid peroxidation, nitrogen dioxide (NO2) may affect the functional properties of both the pulmonary epithelium and endothelium. We evaluated this possibility in 13 mongrel dogs by exposing these animals to 200 or 400 ppm NO2 for 1 h. The changes in pulmonary epithelial permeability (using a radioaerosol technique), FRC, and endothelial function (the removal of radiolabeled serotonin, [14C]5-HT, and prostaglandin E1, [3H]PGE1, from the pulmonary circulation) were measured at 1 h and at 2, 7, or 14 days after NO2 exposure. In another six dogs, we evaluated changes in cell population and albumin in bronchoalveolar lavage (BAL) fluid caused by NO2. In the first two days after NO2 exposure, focal pulmonary edema was documented on microscopy, radioaerosol clearance was delayed, and FRC decreased slightly. BAL showed a marked increase in albumin, but the removal of trace amounts of 5-HT and PGE1 by the endothelium was not altered. All physiologic abnormalities returned to normal with time.

Neutrophil kinetics in the pulmonary microcirculation. Effects of pressure and flow in the dependent lung.

Increases in pulmonary arterial pressure or blood flow raise peripheral white cell count by releasing sequestered leukocytes from the lung. The effects of altered hemodynamics, however, on the leukocyte sequestration site and on the distribution of leukocyte transit times through the pulmonary microcirculation are unknown. We used in vivo fluorescence videomicroscopy to study the passage of individual, fluorescein-isothiocyanate-labeled neutrophils through the pulmonary microcirculation of anesthetized dogs. Pulmonary hemodynamics were altered over a wide range. Regardless of the hemodynamic conditions, the only place that any of the 2,919 observed neutrophils stopped was in the capillaries. The periods of immobility had a wide range, from less than 1 to greater than 1,200 s. Because the cells remained motionless once they stopped and then accelerated suddenly as they regained the free-flowing stream, the obstructions must have been discrete. About a quarter of the capillary pathways had one site of high resistance. Another quarter offered two or more obstructions. In the remaining half, the neutrophils passed rapidly and without pause from arteriole to venule. Increases in pressure and flow decreased the number of times that individual cells stopped. These changes altered the median transit time by shifting the distribution of transit times between the slowest and fastest groups. We conclude that most of the total pathlength of perfused capillaries offers little resistance even to neutrophils. There are, however, focal areas in individual capillaries that offer high resistance to neutrophil passage.

Effect of PAF on parasympathetic contraction of canine airways.

Platelet-activating factor (PAF) increases the bronchoconstrictor response of mammalian airways to cholinergic agonists and is thus implicated as a potential mediator of airway hyperreactivity. This study further defines the nature of the increase in airway responsiveness induced by PAF. We employed an in situ canine tracheal preparation, which allows differentiation of the effects PAF has on airway smooth muscle contraction from confounding effects it has on inducing airway edema and secretions. We found that PAF, infused regionally into tracheal arteries, increases the responsiveness of the trachealis muscle to parasympathetic stimuli in a dose-dependent manner. This effect occurred within 15 min. To determine whether the increase in trachealis muscle responsiveness resulted from effects localized to the trachea, we compared the effect of PAF on the tracheal segment with effects of the lower airways of the lung. Delivered to the arteries perfusing the tracheal segment, PAF did not increase lung resistance during vagus nerve stimulation. These data indicate that airway hyperresponsiveness elicited by PAF results from regional stimulation and/or release of mediators that augment tracheal contractility and that this effect is distinct from systemic effects elicited by PAF.

Endotoxin-pretreated neutrophils increase pulmonary vascular permeability in dogs.

Endotoxin causes pulmonary vascular neutrophil sequestration and injures the lung. Whether this is primarily due to a direct effect of endotoxin on the endothelium or is mediated by an action on the neutrophil is unclear. Canine neutrophils, isolated on plasma-Percoll gradients in vitro, were incubated with Salmonella enteriditis endotoxin, washed, and injected via wedged pulmonary arterial catheters into discrete lung zones of anesthetized dogs, whereas untreated neutrophils were administered into contralateral control lung zones. 113mIn-transferrin was administered intravenously 2 h before the animals were killed. Morphometry and extravascular protein accumulation were assessed at 4 h. Endotoxin treatment of neutrophils ex vivo induced a two- to three-fold increase in neutrophils in these lung zones (0.096 +/- 0.012 vs. 0.05 +/- 0.002 neutrophils/alveolar septal intercept, P less than 0.05). Extravascular-to-intravascular protein ratios in zones receiving endotoxin-treated neutrophils were significantly increased compared with control zones (0.146 +/- 0.02 vs. 0.079 +/- 0.02, P less than 0.05). Because complement fragments increase injury to endothelium in vitro, exogenous C5 fragments were administered to other dogs before administration of neutrophils but failed to significantly increase the extravascular protein signal (0.154 +/- 0.03 vs. 0.124 +/- 0.04). In summary, endotoxin treatment of neutrophils leads to neutrophil sequestration and increased pulmonary extravascular protein accumulation. C5 fragments failed to further enhance the protein accumulation. These data are consistent with an effect of endotoxin on the neutrophil to initiate neutrophil-endothelial interaction and subsequent lung injury.

Evidence from cassette mutagenesis for a structure-function motif in a protein of unknown structure.

The three-dimensional structure of most enzymes is unknown; however, many enzymes may have structural motifs similar to those in the known structures of functionally related enzymes. Evidence is presented that an enzyme of unknown structure [Ile-transfer RNA (tRNA) synthetase] may share a functionally important structural motif with an enzyme of related function (Tyr-tRNA synthetase). This approach involves (i) identifying segments of Ile-tRNA synthetase that have been unusually conserved during evolution, (ii) predicting the function of one such segment by assuming a structural relation between Ile-tRNA synthetase and Tyr-tRNA synthetase, and (iii) testing the predicted function by mutagenesis and subsequent biochemical analysis. Random mutations were introduced by cassette mutagenesis into a ten-amino-acid segment of Ile-tRNA synthetase that was predicted to be involved in the formation of the binding site for isoleucine. Few amino acid substitutions appear to be tolerated in this region. However, one substitution (independently isolated twice) increased the Michaelis constant Km for isoleucine in the adenylate synthesis reaction by greater than 6000-fold, but had little effect on the Km for adenosine triphosphate, the apparent Km for tRNA, or the rate constant kcat.

Physiological neutrophil sequestration in the lung: visual evidence for localization in capillaries.

Although the lung is known to be a major site of neutrophil margination, the anatomic location of these sequestered cells within the lung is controversial. To determine the site of margination and the kinetics of neutrophil transit through the pulmonary microvasculature, we infused fluorescein isothiocyanate-labeled canine neutrophils into the pulmonary arteries of 10 anesthetized normal dogs and made fluorescence videomicroscopic observations of the subpleural pulmonary microcirculation through a window inserted into the chest wall. The site of fluorescent neutrophil sequestration was exclusively in the pulmonary capillaries with a total of 951 labeled cells impeded in the capillary bed for a minimum of 2 s. No cells were delayed in the arterioles or venules. Transit times of individual neutrophils varied over a wide range from less than 2 s to greater than 20 min with an exponential distribution skewed toward rapid transit times. These observations indicate that neutrophil margination occurs in the pulmonary capillaries with neutrophils impeded for variable periods of time on each pass through the lung. The resulting wide distribution of transit times may determine the dynamic equilibrium between circulating and marginated neutrophils.

Accidental inhalation of mercury vapour: respiratory and toxicologic consequences.

Four adults, including a pregnant woman, and three children were admitted to hospital following accidental exposure to mercury vapour produced by heating mercury-gold amalgam. Initial symptoms and signs included a paroxysmal cough, dyspnea, chest pain, tachypnea, nausea, vomiting, fever and leukocytosis. Pulmonary function testing performed on the second day after exposure revealed air-flow obstruction and minor restrictive defects in three patients. The diffusing capacity of the lung for carbon monoxide was reduced in two of these patients. The mean initial blood mercury level (+/- one standard deviation) for the seven patients was 30.8 +/- 1.5 micrograms/dl. A computer analysis showed mercury to behave as a two-compartment system, the compartments having half-lives of 2 and 8 days. The four adults received chelation therapy with D-penicillamine, which did not affect the urinary excretion of mercury. The pregnant woman's infant, born 26 days after exposure, had no detectable clinical abnormalities. The levels of mercury in the blood of the mother and infant at birth and 6 days later were comparable, indicating free transfer of the metal across the placenta.